Form Dop - Application For Dispensing Optician License By Examination Or By Credentials - Alaska Department Of Community And Economic Development Page 2
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8EXAM AND LICENSURE INFORMATION
Alaska requires passage of the National Opticianry Competency Examination (NOCE or ABO) or an equivalent written exam.
License in Spectacles by:
Credentials/Endorsement
Examination
Type:
National Written
State Written
Practical
ABO Certified:
Yes
No
Date
No.
State
Alaska requires passage of the Contact Lens Registry Examination (CLRE) or an equivalent written exam.
License in Contact Lenses by:
Credentials/Endorsement
Examination
Type:
National Written
State Written
Practical
List all states where you hold or have held a license:
State(s)
License Number
Year Granted
Expiration Date
PSYCHOSOCIAL WELL-BEING AND DISCIPLINARY ACTIONS:
Within the last five years:
Yes
No
1.
Has your license in any state or Canadian province been denied revoked, suspended, or
placed on probation? ...................................................................................................................
2.
Have you been treated for emotional or mental illness? ..............................................................
3.
Have you had any problem related to habitual use of drugs or alcohol? .....................................
4.
Have you had any physical or mental disability which may impair or interfere with your ability to
practice as a dispensing optician? ...............................................................................................
5.
Have you been convicted of any criminal offense other than minor traffic violations? ................
If you answered yes to any of the above questions, please explain dates and circumstances on a separate piece of paper, and
send any supporting documents that are applicable.
Please label your letter of explanation and supporting documents with the word "confidential." Affirmative answers to these
questions will be evaluated on a case-by-case basis and in compliance with Administrative Procedures Act.
I HEREBY CERTIFY and declare that I am the person referred to in the foregoing application and that the information
contained in this application is true and correct to the best of my knowledge. I further certify that all credentials supplied by
me are true and correct. I understand that any false information or falsification of credentials may result in failure to obtain a
license to practice as a dispensing optician in the State of Alaska.
ATTACH RECENT
PHOTOGRAPH
Signature of Applicant
(no larger than 3x3)
SUBSCRIBED AND SWORN before me, a Notary Public, in
and for the state of
this
day of
,
.
Notary Public
08-4151 (Rev. 8/00)
My Commission Expires:
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